Maladaptive Eating Patterns,Quality of Life,and Weight Outcomes Following Gastric Bypass: Results of an Internet Survey

Bariatric surgery is the most effective treatment for severe obesity. However, evidence suggests that maladaptive eating behaviors such as binge eating, grazing, and a loss of control when eating may impact postsurgical weight outcomes. The current study sought to characterize the weight outcomes, eating patterns, and perceived health‐related quality of life of individuals 3–10 years following gastric bypass (GBP) surgery and to assess the relationships between eating behaviors, weight outcomes, and quality of life. Eligible participants (N = 497) completed an Internet survey of their eating behaviors, health‐related quality of life, and weight history. Participants self‐reported a mean maximum postsurgical loss of 81% of their excess weight and maintained a mean weight loss of 70% 3–10 years following surgery (mean 4.2 years). Eighty‐seven percent reported weight regain ranging from 1 to 124 lb (mean 22.6 lb). Frequency of binge eating, a loss of control when eating, and grazing were all significantly correlated with greater weight regain (binge eating r = 0.24, P = 0.006; loss of control r = 0.36, P < 0.01; grazing r = 0.39, P < 0.001) and lesser excess weight loss (EWL) (binge eating r = ?0.21, P = 0.013; loss of control r = ?0.41, P < 0.001; grazing r = ?0.27, P < 0.001). Poorer health‐related quality of life was associated with binge eating disorder (BED) (t[463] = 9.7, P < 0.001) and grazing two or more times per week (t[361] = 9.0, P < 0.001). These findings suggest that eating disturbances and a loss of control when eating are significant following GBP and are risk factors for diminished weight outcomes.     

Effectiveness of a Prebariatric Surgery Insurance‐required Weight Loss Regimen and Relation to Postsurgical Weight Loss

Most US insurance companies require patients to participate in a medically supervised weight loss regimen prior to bariatric surgery. However, the utility of this requirement has not been documented. Data was collected from 94 bariatric surgery patients who were required, and 59 patients who were not required, by their insurance company to participate in a presurgical weight loss regimen. Weight change in the required group, as well as group differences in weight change, was examined from 3 and 6 months presurgery to 1 week presurgery, and from 1 week presurgery to 3 months postsurgery. Weight change presurgery was then used to predict weight loss postsurgery. In the 6 months prior to surgery, required patients gained 3.7 kg ± 5.9 (s.d.) (P < 0.0005), which did not differ from nonrequired patients. From surgery to 3 months postsurgery, required patients lost 23.6 ± 8 kg (P < 0.0005), also without differing from nonrequired patients. Patients who gained more weight prior to surgery, lost more weight postsurgery (P = 0.001), while controlling for initial weight. Findings suggest that the common weight loss regimen requirements of US insurance carriers were ineffective in producing presurgical weight loss in this sample. Most patients (>70%) in this sample gained weight prior to surgery, potentially taking advantage of final opportunities to overindulge in preferred foods. Required patients fared no better in terms of weight change postsurgically and, surprisingly, presurgical weight gain predicted better postsurgical weight loss outcome. Several potential explanations for this finding are offered.     

Grazing and loss of control related to eating: two high-risk factors following bariatric surgery

Background: Gastric restrictive surgery induces a marked change in eating behavior. However, the relationship between preoperative and postoperative eating behavior and weight loss outcome has received limited attention. Objective: This study assessed a range of eating behaviors before and 1 year after laparoscopic adjustable gastric banding (LAGB) and explored the nature and extent of change in eating patterns, their clinical associates, and impact on weight loss. Methods and Procedures: A 12‐month observational study assessed presurgical and postsurgical binge eating disorder (BED), uncontrolled eating, night eating syndrome (NES), grazing, nutrient intake and eating‐related behaviors, and markers of psychological distress. A total of 129 subjects (26 male and 103 female, mean age 45.2 ± 11.5 and BMI 44.3 ± 6.8) participated in this study. Results: Presurgical BED, uncontrolled eating, and NES occurred in 14%, 31%, and 17.1% of subjects, which reduced after surgery to 3.1%, 22.5%, and 7.8%, respectively (P = 0.05 for all). Grazing was prevalent before (26.3%) and after surgery (38.0%). Preoperative BED most frequently became grazers (P = 0.029). The average percentage weight loss (%WL) was 20.8 ± 8.5%; range ?0.67 to 50.0% and percentage of excess weight loss (%EWL) 50.0 ± 20.7%; range ?1.44 to 106.9% (P < 0.001). Uncontrolled eating and grazing after surgery showed high overlap and were associated with poorer %WL (P = 0.008 and P < 0.001, respectively) and elevated psychological distress. Discussion: Consistent with recent studies, uncontrolled eating and grazing were identified as two high‐risk eating patterns after surgery. Clearer characterization of favorable and unfavorable postsurgical eating behaviors, reliable methods to assess their presence, and empirically tested postsurgical intervention strategies are required to optimize weight loss outcomes and facilitate psychological well‐being in at‐risk groups.     

Gastric Bypass in a Low‐Income,Inner‐City Population: Eating Disturbances and Weight Loss

Objective: To examine the prevalence of eating disturbances and psychiatric disorders among extremely obese patients before and after gastric bypass surgery and to examine the relationship between these disturbances and weight outcomes. Research Methods and Procedures: Sixty‐five women patients (ages 19 to 67) with a mean BMI of 54.1 were assessed by semistructured psychiatric interview before surgery and by telephone interview after surgery (mean follow‐up: 16.4 months) to determine psychiatric status, eating disturbances, and weight and health‐related variables. Results: Patients lost a mean of 71% of their excess BMI, with significantly poorer weight loss outcomes among African Americans. Psychiatric disorders remained prevalent before (37%) and after (41%) surgery. In contrast, binge eating disorder dropped from 48% to 0%. Psychiatric diagnosis did not affect weight outcomes. Instead, more frequent preoperative binge eating, along with greater initial BMI, follow‐up length, and postoperative exercise, predicted greater BMI loss. Postsurgical health behaviors (exercise and smoking) and nocturnal eating episodes were also linked to weight loss. Exercise frequency increased and smoking frequency tended to decrease after surgery. Discussion: These findings indicated that eating and psychiatric disturbances did not inhibit weight loss after gastric bypass and should not contraindicate surgery. Prior binge eating, eliminated after surgery, predicted BMI loss and, thus, may have previously been a maintaining factor in the obesity of these patients. The association between health behaviors and outcome suggests possible targets for intervention to improve surgical results. Poorer outcomes among African Americans indicate that these patients should be closely monitored and supported after surgery.     

Motivation,Readiness to Change,and Weight Loss Following Adjustable Gastric Band Surgery

High levels of readiness to change (RTC) are considered critical to the long‐term success of weight management programs including bariatric surgery. However, there are no data to support this assertion. We hypothesize that RTC level will not influence weight outcomes following surgery. In 227 consecutive patients undergoing adjustable gastric banding surgery, we recorded reasons for seeking surgery, and RTC measured with the University of Rhode Island Change Assessment. Scores were blinded until study completion. The primary outcome measure was percentage of excess BMI loss at 2 years (%EBMIL‐2); others included compliance and surgical complications. Of 227 subjects, 204 (90%) had weight measurement at 2 years. There was no significant correlation between RTC score and %EBMIL‐2 (r = 0.047, P = 0.5). Using the median split for RTC score the lowest 102 subjects mean %EBMIL‐2 was 52.9 ± 26.9% and the highest 52.2 ± 28.3%, P = 0.869. There was no weight loss difference between highest and lowest quartiles, or a nonlinear relationship between weight loss and RTC score. There was no significant relationship between RCT score and compliance, or likelihood of complications. Those motivated by appearance were more likely to be younger women who lost more weight at 2 years. Poor attendance at follow‐up visits was associated with less weight loss, especially in men. Measures of RTC did not predict weight loss, compliance, or surgical complications. Caution is advised when using assessments of RTC to predict outcomes of bariatric surgery.     

Binge Status and Quality of Life after Gastric Bypass Surgery: A One‐Year Study

Objective: This study evaluated gastric bypass surgery outcomes according to presurgical binge eating severity. Research Methods and Procedures: Adult patients completed assessment questionnaires including the Short Form‐36, Gormally Binge Eating Scale (BES), and Beck Depression Inventory (BDI) before and 12 months after surgery. Results: One hundred nine patients (18 men, 91 women) were recruited. Based on their baseline BES scores, patients were non‐ [n = 52 (48%)], moderate [n = 31 (28%)], or severe [n = 26 (24%)] binge eaters. Although the percentage of excess weight loss was greatest after 12 months in the severe binge eaters, the difference among groups was not significant. Severe binge eaters had higher baseline BDI scores than either non‐ or moderate binge eaters (p = 0.001). After surgery, BDI scores declined significantly in all groups from the baseline scores but remained higher postoperatively in the severe binge eaters (p = 0.018). BES scores declined significantly (p = 0.000) after surgery within all groups. There was no difference in the Short Form‐36 physical component summary scores at baseline among groups. Mental component summary scores were significantly lower in the severe binge eaters (p = 0.001). After surgery, there was no difference among groups in either physical or mental component summary scores. Discussion: In conclusion, data from the present study suggest that patients have similar outcomes in terms of improved depression scores, binge eating behavior, and health‐related quality of life regardless of their binge eating severity before surgery. Patients with the most severe binge eating behavior before surgery showed the most improvement when assessed 12 months after surgery.     

Gastric bypass surgery reduces plasma ceramide subspecies and improves insulin sensitivity in severely obese patients

Bariatric surgery is associated with near immediate remission of type 2 diabetes and hyperlipidemia. The mechanisms underlying restoration of normal glucose tolerance postoperatively are poorly understood. Herein, we examined the effect of Roux‐en‐Y gastric bypass surgery (RYGB) on weight loss, insulin sensitivity, plasma ceramides, proinflammatory markers, and cardiovascular risk factors before and at 3 and 6 months after surgery. Thirteen patients (10 female; age 48.5 ± 2.7 years; BMI, 47.4 ± 1.5 kg/m²) were included in the study, all of whom had undergone laparoscopic RYGB surgery. Insulin sensitivity, inflammatory mediators and fasting lipid profiles were measured at baseline, 3 and 6 months postoperatively, using enzymatic analysis. Plasma ceramide subspecies (C14:0, C16:0, C18:0, C18:1, C20:0, C24:0, and C24:1) were quantified using electrospray ionization tandem mass spectrometry after separation with HPLC. At 3 months postsurgery, body weight was reduced by 25%, fasting total cholesterol, triglycerides, low‐density lipoproteins, and free fatty acids were decreased, and insulin sensitivity was increased compared to presurgery values. These changes were all sustained at 6 months. In addition, total plasma ceramide levels decreased significantly postoperatively (9.3 ± 0.5 nmol/ml at baseline vs. 7.6 ± 0.4 at 3 months, and 7.3 ± 0.3 at 6 months, P < 0.05). At 6 months, the improvement in insulin sensitivity correlated with the change in total ceramide levels (r = ?0.68, P = 0.02), and with plasma tumor necrosis factor‐α (TNF‐α) (r = ?0.62, P = 0.04). We conclude that there is a potential role for ceramide lipids as mediators of the proinflammatory state and improved insulin sensitivity after gastric bypass surgery.     

Mediators of Weight Loss and Weight Loss Maintenance in Middle‐aged Women

Long‐term behavioral self‐regulation is the hallmark of successful weight control. We tested mediators of weight loss and weight loss maintenance in middle‐aged women who participated in a randomized controlled 12‐month weight management intervention. Overweight and obese women (N = 225, BMI = 31.3 ± 4.1 kg/m²) were randomly assigned to a control or a 1‐year group intervention designed to promote autonomous self‐regulation of body weight. Key exercise, eating behavior, and body image variables were assessed before and after the program, and tested as mediators of weight loss (12 months, 86% retention) and weight loss maintenance (24 months, 81% retention). Multiple mediation was employed and an intention‐to‐treat analysis conducted. Treatment effects were observed for all putative mediators (Effect size: 0.32–0.79, P < 0.01 vs. controls). Weight change was ?7.3 ± 5.9% (12‐month) and ?5.5 ± 5.0% (24‐month) in the intervention group and ?1.7 ± 5.0% and ?2.2 ± 7.5% in controls. Change in most psychosocial variables was associated with 12‐month weight change, but only flexible cognitive restraint (P < 0.01), disinhibition (P < 0.05), exercise self‐efficacy (P < 0.001), exercise intrinsic motivation (P < 0.01), and body dissatisfaction (P < 0.05) predicted 24‐month weight change. Lower emotional eating, increased flexible cognitive restraint, and fewer exercise barriers mediated 12‐month weight loss (R² = 0.31, P < 0.001; effect ratio: 0.37), but only flexible restraint and exercise self‐efficacy mediated 24‐month weight loss (R² = 0.17, P < 0.001; effect ratio: 0.89). This is the first study to evaluate self‐regulation mediators of weight loss and 2‐year weight loss maintenance, in a large sample of overweight women. Results show that lowering emotional eating and adopting a flexible dietary restraint pattern are critical for sustained weight loss. For long‐term success, interventions must also be effective in promoting exercise intrinsic motivation and self‐efficacy.     

TNF‐α Promoter Methylation as a Predictive Biomarker for Weight‐loss Response

Tumor necrosis factor‐α (TNF‐α) is a proinflammatory cytokine which is commonly elevated in obese subjects and whose promoter is susceptible to be regulated by cytosine methylation. The aim of this research was to analyze whether epigenetic regulation of human TNF‐α promoter by cytosine methylation could be involved in the predisposition to lose body weight after following a balanced hypocaloric diet. Twenty‐four patients (12 women/12 men) with excessive body weight‐for‐height (BMI: 30.5 ± 0.32 kg/m²; age: 34 ± 4 years old) followed an 8‐week energy‐restricted diet. Blood mononuclear cell DNA, isolated before the nutritional intervention, was treated with bisulfite and a region of TNF‐α gene promoter (from ?360 to +50 bp) was sequenced. Obese men with successful weight loss (≥5% of initial body weight) showed lower levels of total TNF‐α promoter methylation (r = 0.74; P = 0.021), especially in the positions ?170 bp (r = 0.75, P = 0.005) and ?120 bp (r = 0.70, P = 0.011). Baseline TNF‐α circulating levels were positively associated with total promoter methylation (r = 0.84, P = 0.005) and methylation at position ?245 bp (r = 0.75, P = 0.020). TNF‐α promoter methylation could be a good inflammation marker predicting the hypocaloric diet‐induced weight‐loss, and constitutes a first step toward personalized nutrition based on epigenetic criteria.     

The Macrophage‐Specific Serum Marker,Soluble CD163, Is Increased in Obesity and Reduced After Dietary‐Induced Weight Loss

Objective: Soluble CD163 (sCD163) is a new macrophage‐specific serum marker elevated in inflammatory conditions. sCD163 is elevated in obesity and found to be a strong predictor of the development of type 2 diabetes. We investigated whether dietary intervention and moderate exercise was related to changes in sCD163 and how sCD163 is associated to insulin resistance in obesity. Design and Methods: Ninety‐six obese subjects were enrolled: 62 followed a very low energy diet (VLED) program for 8 weeks followed by 3‐4 weeks of weight stabilization, 20 followed a moderate exercise program for 12 weeks, and 14 were included without any intervention. Fasting blood samples and anthropometric measures were taken at baseline and after intervention. Thirty‐six lean subjects were included in a control group. Results: sCD163 was significantly higher in obese subjects (2.3 ± 1.0 mg/l) compared with lean (1.6 ± 0.4 mg/l, P < 0.001). Weight loss (11%) induced by VLED resulted in a reduction and partial normalization of sCD163 to 2.0 ± 0.9 mg/l (P < 0.001). Exercise for 12 weeks had no effect on sCD163. At baseline, sCD163 was significantly correlated with BMI (r = 0.46), waist circumference (r = 0.40), insulin resistance measured by the homeostasis model assessment (HOMA‐IR; r = 0.41; all P < 0.001), and the leptin‐to‐adiponectin ratio (r = 0.28, P < 0.05). In a multivariate linear regression analysis with various inflammatory markers, sCD163 (β = 0.25), adiponectin (β = ?0.24), and high sensitivity C‐reactive protein (hs‐CRP; β = 0.20) remained independently and significantly associated to HOMA‐IR (all P < 0.05). After further adjustment for waist circumference, only sCD163 was associated with HOMA‐IR (P < 0.05). Conclusion: The macrophage‐specific serum marker sCD163 is increased in obesity and partially normalized by dietary‐induced weight loss but not by moderate exercise. Furthermore, we confirm that sCD163 is a good marker for obesity‐related insulin resistance.     

Pigment Epithelium‐Derived Factor,Insulin Sensitivity,and Adiposity in Polycystic Ovary Syndrome: Impact of Exercise Training

Pigment epithelium‐derived factor (PEDF) is upregulated in obese rodents and is involved in the development of insulin resistance (IR). We aim to explore the relationships between PEDF, adiposity, insulin sensitivity, and cardiovascular risk factors in obese women with polycystic ovary syndrome (PCOS) and weight‐matched controls and to examine the impact of endurance exercise training on PEDF. This prospective cohort intervention study was based at a tertiary medical center. Twenty obese PCOS women and 14 non‐PCOS weight‐matched women were studied at baseline. PEDF, cardiometabolic markers, detailed body composition, and euglycemic—hyperinsulinemic clamps were performed and measures were repeated in 10 PCOS and 8 non‐PCOS women following 12 weeks of intensified aerobic exercise. Mean glucose infusion rate (GIR) was 31.7% lower (P = 0.02) in PCOS compared to controls (175.6 ± 96.3 and 257.2 ± 64.3 mg.m^?2.min^?1) at baseline, yet both PEDF and BMI were similar between groups. PEDF negatively correlated to GIR (r = ?0.41, P = 0.03) and high‐density lipoprotein (HDL) (r = ?0.46, P = 0.01), and positively to cardiovascular risk factors, systolic (r = 0.41, P = 0.02) and diastolic blood pressure (r = 0.47, P = 0.01) and triglycerides (r = 0.49, P = 0.004). The correlation with GIR was not significant after adjusting for fat mass (P = 0.07). Exercise training maintained BMI and increased GIR in both groups; however, plasma PEDF was unchanged. In summary, PEDF is not elevated in PCOS, is not associated with IR when adjusted for fat mass, and is not reduced by endurance exercise training despite improved insulin sensitivity. PEDF was associated with cardiovascular risk factors, suggesting PEDF may be a marker of cardiovascular risk status.     

Loss of control is central to psychological disturbance associated with binge eating disorder

Objective: Binge eating disorder (BED) is positively associated with obesity and psychological distress, yet the behavioral features of BED that drive these associations are largely unexplored. The primary aim of this study was to investigate which core behavioral features of binge eating are most strongly related to psychological disturbance. Methods and Procedures: A cross‐sectional study involved 180 bariatric surgery candidates, 93 members of a non‐surgical weight loss support group, and 158 general community respondents (81 men/350 women, mean age 45.8 ± 13.3, mean BMI 34.8 ± 10.8, BMI range 17.7–66.7). Validated questionnaires assessed BED and binge eating, symptoms of depression, appearance dissatisfaction (AD), quality of life (QoL) and eating‐related behaviors. Features of binge eating were confirmed by interview. BMI was determined by clinical assessment and self‐report. Results: The loss of control (LOC) over eating, that is, being unable to stop eating or control what or how much was consumed was most closely related to psychological markers of distress common in BED. In particular, those who experienced severe emotional disturbance due to feelings of LOC reported higher symptoms of depression (P < 0.001), AD (P = 0.009), and poorer mental health–related QoL (P = 0.027). Discussion: Persons who report subjective binge episodes or do not meet BED frequency criteria for objective binge episodes may still be at elevated risk of psychological disturbance and benefit from clinical intervention. Feelings of LOC could drive binge eaters to seek bariatric surgery in an attempt to gain control over body weight and psychologically disturbing eating behavior.     

On the Relation of Attempting to Lose Weight,Restraint, and Binge Eating in Outpatients with Binge Eating Disorder

Objective: To examine the relationship among attempts to lose weight, restraint, and eating behavior in outpatients with binge eating disorder (BED). Research Methods and Procedures: Participants were 93 consecutive outpatients evaluated for a clinical trial who met Diagnostic and Statistical Manual, Fourth edition criteria for BED. The Eating Disorder Examination Interview was administered to assess attempts at weight loss, restraint, different forms of overeating, and the attitudinal psychopathology of eating disorders (i.e., concerns regarding eating, shape, and weight). In addition, the Three‐Factor Eating Questionnaire was used to assess cognitive restraint, hunger, and disinhibition. Psychometrically established measures were given to assess body dissatisfaction, depression, and self‐esteem. Results: The majority of participants (75.3%; N = 70) reported attempting to lose weight, but only 37.6% (N = 35) reported dietary restraint on at least half the days of the month. Dietary restraint and cognitive restraint were not associated with any form of binge eating or overeating. Dietary restraint and cognitive restraint were positively correlated with weight concern, shape concern, and body dissatisfaction, and negatively correlated with body mass index. To further examine the interplay between attempting to lose weight and restraint, three study groups were created: unrestrained nonattempters (21.5%, N = 20), unrestrained attempters (40.9%; N = 38), and restrained attempters (34.4%; N = 32). The three groups did not differ significantly on binge eating or other eating behaviors; however, significant differences were observed for weight concern, shape concern, and body dissatisfaction. Discussion: Attempts to lose weight and restraint are not synonymous for patients with BED. Although 75.3% of BED patients reported that they were attempting to lose weight, only 37.6% reported dietary restraint on at least half the days of the previous month. While restraint was negatively associated with body mass index, it was not related to binge eating or overeating. Our findings raise questions about prevailing models that posit restraint as a predominant factor in the maintenance of binge eating in BED.     

Increased exercise capacity after surgically induced weight loss in morbid obesity

Objective: To investigate the effects of surgically induced weight loss on exercise capacity in patients with morbid obesity (MO). Research Methods and Procedures: A prospective 1‐year follow‐up study was carried out, with patients being their own controls. A symptom‐limited cardiopulmonary exercise stress test was performed in 31 MO patients (BMI > 40 kg/m²) before and 1 year after undergoing bariatric surgery. Results: At 1 year after surgery, weight was reduced from 146 ± 33 to 95 ± 19 kg (p < 0.001), and BMI went from 51 ± 4 to 33 ± 6 kg/m² (p < 0.001). After weight loss, obese patients performed each workload with lower oxygen consumption, heart rate, systolic arterial pressure, and ventilatory volume (p < 0.001). This reduced energy expenditure allowed them to increase the duration of their effort test from 13.8 ± 3.8 to 21 ± 4.2 minutes (p < 0.001). Upon finishing the exercise, MO patients before surgery were able to reach only 83% of their age‐predicted maximal heart rate, and their respiratory exchange ratio was 0.87 ± 0.06. After weight loss, those values were 90% and 1 ± 0.08, respectively (p < 0.01). When we compared the peak O₂ pulse corrected by fat free mass before and after surgery, no significant differences between the groups were found. Discussion: After surgically induced weight loss, MO patients markedly improved their exercise capacity. This is due to the fact that they were able to perform the external work with lower energy expenditure and also to increase cardiovascular stress, optimizing the use of cardiac reserve. There were no differences in cardiac function before and after surgery.     

Long-Term,Sustained, Lifestyle-Induced Weight Loss in Severe Obesity: the Get-Real Program

Objective: To study the long-term effectiveness of a patient-centered, multidisciplinary lifestyle intervention treatment in patients medically eligible for bariatric surgery.Methods: Using a case-control study design, we compared treatment results for 98 adults (mean body mass index [BMI], 44.2 kg/m²) with the outcomes of 148 controls (mean BMI, 43.0 kg/m²) receiving standard care. The approach included a phased triage for inclusion, followed by 12 lifestyle intervention group sessions alternating with individual visits for behavior, diet, and exercise instructions.Results: At 2 years, weight loss averaged 15.3 ± 1.4 kg (P<.0010) (12 ± 1% of initial body weight [IBW], P<.001; 21 ± 2% of excess body weight [EBW], P<.001) in an intention-to-treat (ITT) analysis; in completers, weight loss was 18.8 ± 1.5 kg (P<.001) (15 ± 1% IBW, P<.001; 26 ± 3% EBW, P<.001). A total of 42 patients lost ≥10% IBW. Controls remained weight stable (P =.35); 3% lost ≥10% IBW. Patients achieving weight loss that would be considered satisfactory for bariatric surgery included 20% who achieved ≥35% EBW loss, 29% who achieved a BMI <35 kg/m² (if starting BMI <50 kg/m²) or BMI <40 kg/m² (if starting BMI ≥50 kg/m²), and 37% who achieved EBW loss ≤50%. These values for completers were 31, 39, and 48%, respectively. In the 55 patients starting the program ≥4 years ago, weight loss maintenance of 12 ± 1% IBW (ITT, 16 ± 1% in completers) was observed.Conclusion: Substantial nonsurgical weight loss, maintained at 2 to 4 years, is achievable in severely obese patients using comprehensive lifestyle approaches; the efficacy/safety trade-off in obesity treatment is an important consideration in interpreting these results.Abbreviations: BMI = body mass index EBW = excess body weight HbA_1c = glycated hemoglobin IBW = initial body weight LOCFA = last observation carried forward analysis     

Hepatic Expression of Cell Death–inducing DFFA‐like Effector C in Obese Subjects Is Reduced by Marked Weight Loss

The hepatic expression of the cell death–inducing DNA fragmentation factor A–like effector family (CIDEA, CIDEB, and CIDEC) genes is markedly upregulated in mouse models of obesity. We evaluated the expression of CIDE genes in liver of obese human subjects undergoing gastric bypass surgery (GBS), at the time of surgery and again 1 year later when subjects had lost 37.6 ± 1.4% of their initial body weight. At the time of GBS, the expression of CIDEA (r² = 0.20, P = 0.04) and CIDEC (r² = 0.32, P = 0.01) was strongly correlated with BMI, whereas CIDEB was not (r² = 0.01, P = 0.81). One year after surgery, CIDEC expression had declined over 60% (P = 0.02), whereas CIDEA expression did not change (P = 0.20). These data demonstrate that, consistent with previous studies conducted in rodents, hepatic expression of CIDEA and CIDEC, but not CIDEB, is increased in obese humans. Moreover, the hepatic expression of CIDEC is downregulated by marked weight loss.     

Family Physicians' Practices and Attitudes Regarding Care of Extremely Obese Patients

Despite the growing epidemic of extreme obesity in the United States, weight management is not adequately addressed in primary care. This study assessed family physicians' practices and attitudes regarding care of extremely obese patients and factors associated with them. A cross‐sectional, self‐administered survey was mailed to 500 family physicians in New Jersey (NJ) during March–May 2008. Measures included knowledge, weight management approaches, attitudes toward managing obesity, challenges with examinations, availability of supplies, and strategies to improve care. Response rate was 53% (N = 255). Bariatric surgery and weight loss medications were infrequently recommended, particularly in physicians with higher volume of extremely obese patients (odds ratio (OR) 0.38; 95% confidence interval (CI) 0.23, 0.62 and OR 0.51; 95% CI 0.31, 0.85 for surgery and medications, respectively). Higher knowledge was associated with increased frequency of recommendations of weight loss medications (P < 0.0001) and bariatric surgery (P < 0.0001). There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight‐loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002). Many providers encountered challenges performing examinations on extremely obese patients. More education of primary care physicians, particularly on bariatric surgery, specific examination techniques, and availability of community resources for obese persons is needed. Further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients.     

Maintenance of weight loss in overweight middle-aged women through the Internet

Objective: The purpose of this study was to compare weight regain in a group of perimenopausal women (48.0 ± 4.4 years old), randomized to a 12‐month weight maintenance Internet intervention or to self‐directed weight maintenance after a 4‐month weight loss treatment. Methods and Procedures: After a 4‐month behavioral weight loss program, 135 women were randomized to either Internet or self‐directed groups. The Internet group (n = 66) used a website to gain information and complete logs concerning their weight, diet, and exercise progress over a 12‐month follow‐up. The 69 self‐directed women had no contact with study staff. All women were measured for weight and body composition, and diet intake, and were interviewed using the 7‐day physical activity questionnaires at baseline, 4 months, and 16 months. Results: At the end of the 12‐month follow‐up, the Internet and self‐directed groups had regained on average 0.4 ± 5.0 kg and 0.6 ± 4.0 kg, respectively (P = 0.5). In within‐group analyses, Internet diet‐log entries were correlated with follow‐up weight change (r = ?0.29; P < 0.05) and moderately with change in exercise energy expenditure (EEE; r = 0.44; P < 0.01). Follow‐up weight change was not correlated with change in dietary intake. Discussion: While significant weight loss was maintained over follow‐up by both groups of women, Internet use did not surpass self‐direction in helping to sustain weight loss. Among Internet users, Internet use was related to weight change and EEE.     

Do Psychosocial Variables Predict Weight Loss or Mental Health after Obesity Surgery? A Systematic Review

Objective: The objective of this study was to present a systematic review of psychological and psychosocial predictors of weight loss and mental health after bariatric surgery. This systematic review included all controlled and noncontrolled trials of the last 2 decades with either a retrospective or prospective design and a follow‐up period of at least 1 year. Research Methods and Procedures: The relevant literature was identified by a search of computerized databases. All articles published in English and German between 1980 and 2002 were reviewed. Results: Using the above inclusion/exclusion criteria, 29 articles were identified focusing on psychosocial predictors of weight loss and mental health after obesity surgery. Discussion: Personality traits have no predictive value for the postoperative course of weight or mental state. Apart from serious psychiatric disorders including personality disorders, psychiatric comorbidity seems to be of more predictive value for mental and physical well‐being as two essential aspects of quality of life than for weight loss postsurgery. However, depressive and anxiety symptoms as correlates of psychological stress with regard to obesity seem to be positive predictors of weight loss postsurgery. The severity of the symptoms or the disorder is more relevant for the outcome of obesity surgery than the specificity of the symptoms. It is also not solely the consumption of distinct “forbidden” foods, such as sweets or soft drinks, but rather a general hypercaloric eating behavior, either as an expression of the patient's inadequate compliance or a dysregulation in energy balance, which is associated with a poor weight loss postsurgery.     

Effect of Orlistat in Obese Patients with Binge Eating Disorder

Objective: Binge eating disorder represents a significant public health problem, with up to 50% of weight loss program participants displaying this disorder. In previous studies with orlistat, patients with binge eating disorder were excluded. The goal of this study was to assess the efficacy of orlistat in obese patients with binge eating disorder. Research Methods and Procedures: Eighty‐nine patients with clinically diagnosed binge eating disorder and a BMI ≥ 30 kg/m² were randomized in double‐blind fashion to 24 weeks of treatment with 120 mg of orlistat or placebo three times daily, in combination with a mildly reduced‐calorie diet. Results: After 24 weeks, the mean weight loss from baseline for orlistat‐treated patients was significantly greater than for patients receiving placebo (?7.4% vs. ?2.3%; p = 0.0001) (intent‐to‐treat analysis). The overall Eating Disorder Inventory 2 score at week 24 was significantly lower in patients treated with orlistat than in those in the placebo group (p = 0.011) Discussion: Orlistat may be considered as part of the management for patients with obesity and binge eating disorder.